Addi van Bergen

Cumulation of ill health and low agency 135 6 A second direction is addressing the convergence of health and social problems in this population segment. Cross-domain working is still in its infancy and in practice, it is hard to get off the ground [3]. The Dutch programme ”The Right Care in the Right Place” sets an example by advocating a different perspective on sickness and health, with more focus on what people need to be able to function and less on what the care system has to offer, starting with people’s capabilities, vitality, resilience and wishes [3]. A good example is the introduction of Powerful Basic Care (Krachtige Basiszorg) within deprived areas in the G4 [49]. In social care, more attention should be given to health and health promotion. A third direction is paying more attention to upstream policies at the meso and macro levels. SE is not just an individual problem. Lack of social cohesion, discrimination and stigma, deprived neighbourhoods, complex bureaucratic procedures, individualization, high demands on people’s self-reliance and lagging social benefits are all factors that affect SE and health. The issue we should pursue is how to ensure that people who are on social benefits, and those we are unemployed or disabled and cannot work, can participate fully in our society; i.e., how do we make our institutions inclusive and build up self-respect and agency instead of distorting these capabilities? A good example here is the application of scientific evidence, e.g., on Mobility Mentoring®, to create stress-sensitive services within the municipality of Utrecht [47]. Room for future social experiments and comparative research is needed. The fourth and last direction is not forgetting those who have already fallen through the cracks of society, i.e., the homeless, people living in protected and sheltered housing, detainees and undocumented immigrants, all of whom did not participate in this research. It is important to incorporate these groups in regular health care, prevention and social policies to prevent further exclusion. Strengths and limitations This study has some major strengths and limitations. The strong points include the use of a large representative sample, the inclusion of all major lifestyle and health outcomes in terms of mortality and morbidity and the employment of validated instruments to measure social exclusion, anxiety and depression symptoms and personal control. The limitations are as follows. First, as in any cross-sectional study, no causal relations could be examined. The PAFs calculated in this study are largely theoretical and do not necessarily hold in practice. The PAFs herein represent the proportional reduction in overall morbidity or unhealthy behaviour that would occur if the lowest social stratum would experience the same rate as the rest of the population. No rigorous statistical testing took place, as this was not considered relevant for the purpose of the research and the exploratory nature of the study. In addition, confounding has not been taken into account. Our goal was to identify population segments with high levels of ill health and low personal control in a given context. In a different social context, a comparable study could lead to different results. We expect, based on additional